IntraPet Ultrasound Patient Information Form

To schedule, please

TEXT: 410-849-6867 or

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CONFIRMED APPOINTMENT DATE: Confirmed with owner and IntraPet and cancellation fees are accepted. Leave BLANK if not confirmed with IntraPet.

REQUESTED DATES for ultrasound if not already confirmed with IntraPet (format: month/day).

Notes regarding scheduling may be added here

DVM Name

Hospital Name (No acronyms or #’s) *

Pet Name *

Owner Last Name *

Date of Birth *

Date

Weight (specify lbs or kg) *

Species/Breed *

Sex *

Ultrasound Exam-select all that apply. (Abdominal includes urinary & repro) *

Abdominal Echocardiogram (Heart function) Specialty-Chest, Urinary, Thyr, Preg Procedure-FNA, ECG, OTHER

If Specialty or Procedure specify type:

(Urinary, Thyroid, Chest, Pregnancy, ECG, FNA)

Previous IntraPet Ultrasound? *

Date of Previous IntraPet Ultrasound

DVM/EMPLOYEE PET *

STAT report (same day report within 2-4 hours of ultrasound, additional fee applies)

YES, please submit a STAT report. NO, we are not requesting a stat report at this time.

Presenting Complaint/History/PE *

Tentative diagnosis/ Questions to be answered with ultrasound *

Brief abnormalities for Lab Results/Radiograph Findings (please upload full results or email intrapetstaff@gmail)

*PLEASE DO NOT INCLUDE ENTIRE MEDICAL CHARTS/VISIT NOTES ETC. LABS/RADS/TEST RESULTS ONLY

Medications with dosage and duration

If concern for second cavity pathology is seen during a scan, (ex: splenic mass, pleural effusion, enlarged abd vessels, mass in chest during echo), a limited second cavity scan is approved at $35 *

Confidential questions/concerns, information for specialist/sonographer. WILL NOT APPEAR ON FINAL REPORT

Despite using calming and relaxing methods, sedation may be deemed necessary by the Sonographer to achieve a full diagnostic ultrasound. Even a seemingly relaxed patient may need sedation due to abdominal wall tension or excessive patient movement. Please discuss sedation with the owner prior to the date of the ultrasound.

Sedation is NOT a requirement, it is recommended with some patients but it is ultimately the decision of DVM and the owner. *Certain sedatives interfere with echocardiograms, please contact us with any questions prior to injection.

Sedation—please choose one, any special circumstances can be listed in box below *

YES, IV sedation is approved if deemed necessary at the time of the appt for a diagnostic scan (provide dosages below or in medical notes) YES, IM sedation is approved and will be given prior to IntraPet arrival. I accept the fee incurred if the clinic does not contact IntraPet the morning of the scan. NO, sedation is declined. We accept the conditions stated below.*

*CONDITIONS FOR SEDATION CHOICE "NO":

IntraPet will not ask for sedation at the time of the scan if "NO" is selected, even if patient condition prevents a diagnostic scan.

If sedation choice is "NO", this indicates DVM/owner have declined sedation. A partial scan may be submitted at full charge if patient condition prevents a complete diagnostic scan or no scan will be performed and a fee will apply.

Sedation: please type dosages (or “in medical chart”) and/or notes regarding sedation. Sedation doses must be available at time of scan.

Lab work / Rads

Please enter your Email to receive a PDF copy of this form for your records. Your form will be editable from the link you receive at this email. *

example@example.com

Secondary email if above email is not clinic email.

example@example.com

I have contacted IntraPet by text or separate email to schedule this exam: *

YES, I have contacted IntraPet. NO, I have not contacted IntraPet and will do so after this form submission.

TEXT/CALL 410-849-6867 or EMAIL intrapetstaff@gmail

THANK YOU!

IntraPet Patient Information